Examination of lacrimal organs

Exterior examination of lacrimal organs

1. The marginal tear stream of both eyes is examined with a slit lamp before other manipulations on the eyelids or by instillation of local preparations that can change the clinical picture. Many patients with tearfulness do not have pronounced lachrymation, but when examined they are diagnosed with a high marginal tear stream on the affected side.
2. The eyelids are examined for lacrimal ligation. Usually the lower tear points are turned to the eyeball and can not be seen without turning the edge of the eyelids. One of the most common causes of eyelid inversion and, hence, tear point is ectropion, which can have an involutional, paralytic or scarred etiology. Such an ectropion may involve the lacrimal part of the lacrimal point. A rare cause of lacrimation is Centurion syndrome. In patients with this syndrome, lachrymation manifests itself in childhood and is associated with the reversal of the middle part of the century with the displacement of the tear point from the lacrimal lake due to the strongly protruding bridge of the nose. Sometimes the stasis of tears can be caused by a large teary flesh that displaces the lower lacrimal point outside of the eyeball, or the obstruction of the lower tear point by an excess fold of the conjunctiva (conjunctivahalasis).
3. It is necessary to evaluate the dynamics of the closure of the century. Usually, when the edges of the eyelids are completely closed, tear points are connected. In patients with weakness of the lower eyelid, the upper eyelid can turn the lower eyelid or overlap the lacrimal point.
4. Tear point is better to investigate in the light slit lamp. In addition to eversion, the teardrop can be inflamed, stenotic or obturated, sometimes with an eyelash. The canal is characterized by swelling of the lacrimal point and the release of pus when pressing on the tubules with a finger or a glass rod. Pathology in children is represented by the development of a lacrimal point, an additional teardrop or a congenital lacrimal fistula. 
5. The lacrimal sac first palpates. When you click on the tear ducts, you can observe the expression of mucous contents in patients with mucoceles in the tubule system, but with obstruction distal to the lower end of the lacrimal sac. With acute dacryocystitis, palpation is very painful, and it is better to avoid strong pressure. Sometimes, when palpation of the lacrimal sac, a compaction or swelling is found. 
6. The test for the delay (elution) of fluorescein is performed by instillation of fluorescein 2% into both conjunctival cavities. Usually, after 3 min, fluorescein does not remain or the minimum amount remains. A prolonged delay in the conjunctival cavity indicates a lack of drainage of the tear.

[1], [2], [3], [4], [5]

Sounding and washing

Perform only after the patency of the lacrimal point. Under local anesthesia, a slightly curved, dull lacrimal cannula on a syringe containing 2 ml of hypertonic solution is inserted into the lower lacrimal point and advanced along the tubule. When you try to enter a tear sack, the middle wall of which is located opposite the bone lacrimal fossa, the canula can rest against a hard or soft wall.

1. A firm obstacle. If the cannula enters a tear sack, it rests against its medial wall, through which you can feel a hard lacrimal bone. This eliminates the complete obstruction of the canal system. The doctor places a finger over the tear pit and injects the solution. If the solution enters the nose - the patient's tear ducts are passable. If there is an obstruction of the nasolacrimal canal, the solution does not enter the nose, which means either stenosis of the lacrimal canal or a disturbance of the lacrimal pump mechanism. In this situation, in irrigation, the tear sack grows in size and the liquid is poured back through the upper lacrimal point. Regurgitated material can be clean, mucous, mucopurulent or purulent, depending on the contents of the lacrimal sac.
2. Soft obstacle. If the cannula rests on the proximal joint of the common tubule and lacrimal sac, i.e. In the side wall of the bag, not reaching it, there is a soft resistance, because the cannula rests against the soft tissues of the common tubule and the side wall of the bag. When irrigation, the bag does not increase in size. In the case of lower obstruction of the tubules, the reflux of the solution will pass through the lower lacrimal point. Reflux through the upper lacrimal point indicates the patency of both the upper and lower tubules in obstruction of the common tubule.

Test Jones

It is administered to patients with an alleged partial obstruction of the drainage system. They have more pronounced tearfulness, but the tear system can be well passable. The test with staining does not matter with complete obstruction.

The tubal test (the first test) differentiates the partial obstruction of lacrimal passages from the primary hypersecretion of the tear. Initially, instill fluorescein 2% into the conjunctival cavity. Approximately 5 m. A cotton swab soaked with a local anesthetic is inserted into the lower nasal passage at the exit site of the nasolacrimal canal. The result is interpreted as follows.

• positive: a cotton swab removed from the nose and colored with fluorescein indicates the patency of the lacrimal passages. Lachrymation is associated with primary hypersecretion, so there is no need for further research;
• negative: the cotton swab is not stained, therefore, there is a partial obstruction (the place is unknown) or the tear pump is not working. In this situation, a second test is performed immediately.

In 22% of healthy people, the first Jones test is negative.

The nasal test (the second test) reveals a probable site of partial obstruction based on the fluorescein intake, milled at the first test. The installation of a local anesthetic removes all residual fluorescein. Then a saline solution is introduced into the suture system, with a cotton swab at the lower nasal passage.

• positive: fluorescein-colored saline enters the nose, indicating that fluorescein has penetrated into the lacrimal sac. Thus, the functional consistency of the upper lacrimal tract is confirmed, partial obstruction of the nasolacrimal pathways is excluded;
• negative: unpainted saline enters the nose, indicating that. That fluorescein did not get into the lacrimal sac. This means partial obstruction of the upper lacrimal passage (lacrimal point, tubules or common tubule) or a violation of the mechanism sucking the tear fluid.